Impact of smokeless tobacco policies
Authors: Gargi S Sarode, Sachin C Sarode, Rahul Anand
Journal: The Lancet Global Health (2023)

We commend Aastha Chugh and colleagues (June, 2023)1Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar for their systematic review of policies related to smokeless tobacco and their investigation into the prevalence of smokeless tobacco use. The authors have rightly emphasised the importance of developing standardised methodologies for assessing the impact of smokeless tobacco policies. It is unfortunate that, even after two decades since the release of the WHO Framework Convention on Tobacco Control in 2003, we are still grappling with the challenge of determining the true impact of policies on smokeless tobacco.2WHOWHO framework convention on tobacco control 2003: overview.https://fctc.who.int/who-fctc/overviewDate: Feb 27, 2005Date accessed: May 31, 2023Google Scholar Southeast Asian countries warrant special attention, as smokeless tobacco consumption is highly prevalent, with a corresponding major share of related disease burden. Ironically, out of the 18 studies included in the systematic review, only four are from Asian countries (three from India and one from Pakistan). Most of the studies are from high-income and upper-middle-income countries (14 out of the 18).1Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Insufficient attention has been given to the countries where analysis is needed the most, which has resulted in an investigation that is not comprehensive. Additionally, it is concerning that three of the four studies from Asia showed weak methodological quality.1Chugh A Arora M Jain N et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar How can policy makers construct reforms when there is dearth of evidence in the literature? Moreover, the absence of a standardised definition for evaluating the impact of smokeless tobacco policies in the field further compounds the disappointment. Tobacco imposes a substantial economic burden, representing over 1% of India's gross domestic product.3John RM Sinha P Munish VG Tullu FT Economic costs of diseases and deaths attributable to tobacco use in India, 2017–2018.Nicotine Tob Res. 2021; 23: 294-301Crossref Scopus (25) Google Scholar Additionally, expenses incurred solely by treating tobacco-related illnesses amounts to 5·3% of India's total health-care costs, including both private and public expenditures, annually.3John RM Sinha P Munish VG Tullu FT Economic costs of diseases and deaths attributable to tobacco use in India, 2017–2018.Nicotine Tob Res. 2021; 23: 294-301Crossref Scopus (25) Google Scholar It is conceivable that reduced prevalence of smokeless tobacco use would not only reduce the disease burden (eg, from oral cancer and coronary heart disease), but also reduce the national economic burden. Despite knowing this fact, effective examples of implementation of smokeless tobacco policies in Asian countries are still scarce.4Siddiqi K Vidyasagaran AL Readshaw A Croucher R A policy perspective on the global use of smokeless tobacco.Curr Addict Rep. 2017; 4: 503-510Crossref PubMed Scopus (16) Google Scholar This shows the vested interests of tobacco industries and government officials. Perhaps the constant promotion of surrogate advertisements by celebrities on smokefree products, ill-regulated sales to minors, and sales of gutkha in two-packet form (a form of chewing betel with the tobacco included separately), are the best examples of this collusion. These marketing practices could be undermining efforts to control smokeless tobacco consumption and acting as obstacles to the implementation of the WHO Framework Convention on Tobacco Control. Rather than focusing solely on investigating the impact of policies, it is imperative to examine the impact of these loopholes on the prevalence of smokeless tobacco habits, the associated disease burden, and the economic implications for the country. We declare no competing interests. The global impact of tobacco control policies on smokeless tobacco use: a systematic reviewMany countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use. Full-Text PDF Open Access